Subcontractor COVID-19 Exposure Self-Assessment Form
Personal Information
Full Name
Company Name
Date
Phone Number
Email Address
Health Screening Questions
1. Have you experienced any of the following symptoms in the past 14 days?
Fever or chills
Cough
Shortness of breath or difficulty breathing
Fatigue
Other:
2. Have you been in close contact with anyone who has tested positive for COVID-19 within the past 14 days?
Yes
No
3. Have you been diagnosed with COVID-19 in the past 14 days?
Yes
No
4. Are you currently awaiting the results of a COVID-19 test?
Yes
No
5. Have you traveled internationally in the past 14 days?
Yes
No
Certification
I certify that the information provided is accurate to the best of my knowledge.
Signature
Date